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Criteria for intensive/inpatient treatment service

The following criteria will be used for assessing suitability to entry into the intensive/inpatient service. The criteria are not absolute, and will be used as a guide when considering individuals for intensive treatment.

a. Comorbid diagnoses of Obsessive-Compulsive Personality Disorder (OCPD) or Asperger’s Syndrome are not absolute contraindications, but they should not be the primary diagnosis and full criteria for OCD should be met. The severity of symptoms should be significant enough to indicate that personality disorder is insufficient to account for the impairments in functioning.

b. Similarly, comorbid anxiety disorders (e.g. Generalized Anxiety Disorder, Agoraphobia) and depression are common in OCD. These are not a contraindication to admission, but it is expected that efforts have been made to determine that OCD is the primary source of the anxiety symptoms. Such efforts are likely to involve targeted treatment of the other conditions.

2. Symptoms of OCD have persisted for ≥ 2 years without improvement and despite treatment. In the majority of cases, total duration of illness is expected to be in excess of 5 years;

3. Severity of OCD, measured using the clinician-rated Y-BOCS, is likely to be ≥ 28 (severe). In most cases, it is expected that symptoms will be in the ‘extreme’ range (≥ 32);

4. Global Assessment of Functioning (GAF) should be ≤ 40. This means that symptoms are severe and result in “…major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood”. It is unlikely, for example, that patients are able to work or function adequately in any major area and they will be dependent on family, carers, or services.

5. The patient has had ≥ 3 trials of serotonin re-uptake inhibitors at maximum (or maximum-tolerated) dose – one of which should be Clomipramine. Each trial should have been for ≥ 12 weeks;

6. The patient has had at least two trials of antipsychotic augmentation with one or more of the following: Risperidone, Aripiprazole, or Quetiapine.[1] The augmentation trial should be ≥ 6 weeks in duration, and ideally 8-12 weeks. Augmentation of Clomipramine with an antipsychotic drug (wherever tolerated) should have been completed.

7. The patient has had at least one unsuccessful trial of Exposure and Response Prevention, being ≥ 20 hours in duration. This should have been delivered by a therapist with experience in the treatment of OCD. Therapy should have been home-based where symptoms relate to the home environment. Documentation of treatment should be sufficient to appraise the content, delivery, and outcome of such treatment.

Exclusion Criteria

1. Demonstrated lack of willingness to engage in behavioural therapy, or evidence of intolerability to levels of anxiety associated with ERP.

2. Insufficient insight to understand the model and rationale for treatment.

3. Concurrent substance misuse disorder which requires any intervention other than continuation of maintenance treatment.

4. Concurrent major depressive illness that is severe enough to impair ability to engage in ERP or carries a significant risk of self-harm and/or suicide.